Cardiac rhythm management system using time-domain heart rate variability indicia

ABSTRACT

A cardiac rhythm management system that provides an indication of patient well-being based on the autonomic balance between the sympathetic and parasympathetic/vagal components of the autonomic nervous system, using time-domain processing of frequency components of a heart rate interval signal.

RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.09/802,316, filed on Mar. 8, 2001, now issued as U.S. Pat. No.6,678,547, the specification of which is incorporated herein byreference.

TECHNICAL FIELD

The present system relates generally to cardiac rhythm managementsystems and particularly, but not by way of limitation, to such a systemusing time-domain heart rate variability indicia.

BACKGROUND

When functioning properly, the human heart maintains its own intrinsicrhythm, and is capable of pumping adequate blood throughout the body'scirculatory system. However, some people have irregular cardiac rhythms,referred to as cardiac arrhythmias. Such arrhythmias result indiminished blood circulation. One mode of treating cardiac arrhythmiasuses drug therapy. Drugs are often effective at restoring normal heartrhythms. However, drug therapy is not always effective for treatingarrhythmias of certain patients. For such patients, an alternative modeof treatment is needed. One such alternative mode of treatment includesthe use of a cardiac rhythm management system. Such systems are oftenimplanted in the patient and deliver therapy to the heart.

Cardiac rhythm management systems include, among other things,pacemakers, also referred to as pacers. Pacers deliver timed sequencesof low energy electrical stimuli, called pace pulses, to the heart, suchas via an intravascular leadwire or catheter (referred to as a “lead”)having one or more electrodes disposed in or about the heart. Heartcontractions are initiated in response to such pace pulses (this isreferred to as “capturing” the heart). By properly timing the deliveryof pace pulses, the heart can be induced to contract in proper rhythm,greatly improving its efficiency as a pump. Pacers are often used totreat patients with bradyarrhythmias, that is, hearts that beat tooslowly, or irregularly. Such pacers coordinate atrial and ventricularcontractions to improve pumping efficiency. Cardiac rhythm managementsystems also include coordination devices for coordinating thecontractions of both the right and left sides of the heart for improvedpumping efficiency.

Cardiac rhythm management systems also include defibrillators that arecapable of delivering higher energy electrical stimuli to the heart.Such defibrillators also include cardioverters, which synchronize thedelivery of such stimuli to portions of sensed intrinsic heart activitysignals. Defibrillators are often used to treat patients withtachyarrhythmias, that is, hearts that beat too quickly. Such too-fastheart rhythms also cause diminished blood circulation because the heartisn't allowed sufficient time to fill with blood before contracting toexpel the blood. Such pumping by the heart is inefficient. Adefibrillator is capable of delivering an high energy electricalstimulus that is sometimes referred to as a defibrillation countershock,also referred to simply as a “shock.” The countershock interrupts thetachyarrhythmia, allowing the heart to reestablish a normal rhythm forthe efficient pumping of blood. In addition to pacers, cardiac rhythmmanagement systems also include, among other things,pacer/defibrillators that combine the functions of pacers anddefibrillators, drug delivery devices, and any other implantable orexternal systems or devices for diagnosing or treating cardiacarrhythmias.

One problem faced by physicians treating cardiovascular patients isassessing patient well-being for providing a prognosis or for adjustingtherapy to improve the patient's prognosis. Heart rate variability(“HRV”) is thought to provide one such assessment of cardiovascularhealth. The time interval between intrinsic ventricular heartcontractions changes in response to the body's metabolic need for achange in heart rate and the amount of blood pumped through thecirculatory system. For example, during a period of exercise or otheractivity, a person's intrinsic heart rate will generally increase over atime period of several or many heartbeats. However, even on abeat-to-beat basis, that is, from one heart beat to the next, andwithout exercise, the time interval between intrinsic heart contractionsvaries in a normal person. These beat-to-beat variations in intrinsicheart rate are the result of proper regulation by the autonomic nervoussystem of blood pressure and cardiac output; the absence of suchvariations indicates a possible deficiency in the regulation beingprovided by the autonomic nervous system.

The autonomic nervous system itself has two components: sympathetic andparasympathetic (or vagal). The sympathetic component of the autonomicnervous system is relatively slow acting, and is associated with atendency to raise heart rate, blood pressure, and/or cardiac output. Theparasympathetic/vagal component of the autonomic nervous system, whichprovides a relatively faster response than the sympathetic component, isassociated with a tendency to reduce heart rate, blood pressure, and/orcardiac output. A proper balance between the sympathetic andparasympathetic components of the autonomic nervous system is important.Therefore, an indication of this balance of the components of theautonomic nervous system, which is sometimes referred to as “autonomicbalance,” “sympathetic tone,” or “sympathovagal balance,” provides auseful indication of the patient's well-being.

One technique for providing an indication of the balance of thecomponents of the autonomic nervous system is provided by thebeat-to-beat heart rate variability, as discussed above. Moreparticularly, intrinsic ventricular contractions are detected. The timeintervals between these contractions, referred to as the R—R intervals,are recorded after filtering out any ectopic contractions, that is,ventricular contractions that are not the result of a normal sinusrhythm. This signal of R—R intervals is typically transformed into thefrequency-domain, such as by using fast Fourier transform (“FFT”)techniques, so that its spectral frequency components can be analyzed.Two frequency bands are of particular interest: a low frequency (LF)band in the frequency (“f”) range 0.04 Hz≦f<0.15 Hz, and a highfrequency (HF) band in the frequency range 0.15 Hz≦f≦0.40 Hz. The HFband of the R—R interval signal is influenced only by theparasympathetic/vagal component of the autonomic nervous system. The LFband of the R—R interval signal is influenced by both the sympatheticand parasympathetic components of the autonomic nervous system.Consequently, the ratio LF/HF is regarded as a good indication of theautonomic balance between sympathetic and parasympathetic/vagalcomponents of the autonomic nervous system. An increase in the LF/HFratio indicates an increased predominance of the sympathetic component,and a decrease in the LF/HF ratio indicates an increased predominance ofthe parasympathetic component. For a particular heart rate, the LF/HFratio is regarded as an indication of patient wellness, with a lowerLF/HF ratio indicating a more positive state of cardiovascular health.

Such spectral analysis of the frequency components of the R—R intervalsignal has required an FFT (or other parametric transformation, such asautoregression) transformation from the time domain into the frequencydomain. Implantable cardiac rhythm management devices, however,typically do not presently have the dedicated hardware to perform suchFFT transformations. Even if an implantable cardiac rhythm managementdevice did have such dedicated FFT hardware, performing thetransformation would be computationally expensive, requiring increasedpower consumption, and shortening time during which the implantedbattery-powered device can be used before its replacement is required.Therefore, there is a need to provide such an indication of patientwell-being without requiring a computationally expensive transformationof the R—R interval signal into the frequency domain.

SUMMARY

This document describes a cardiac rhythm management system that providesan indication of patient well-being based on the autonomic balancebetween the sympathetic and vagal components of the autonomic nervoussystem, using time-domain processing of frequency components of a heartrate variability signal.

In one embodiment, the cardiac rhythm management system provides amethod that detects heart contractions over a time period. A time-domainfirst signal represents time intervals between the detected heartcontractions. The first signal is filtered to obtain a time-domainsecond signal including frequency components substantially in a firstfrequency band. The first signal is also filtered to obtain atime-domain third signal including frequency components substantially ina second frequency band that is different from the first frequency band.Based on the second and third signals, the system provides an indicationassociated with an autonomic nervous system.

In another embodiment, the cardiac rhythm management system provides amethod that detects contractions of a heart over a time period. Atime-domain first signal represents time intervals between the detectedheart contractions. The first signal is filtered to obtain a time-domainsecond signal having frequency components substantially in a firstfrequency band. The system provides a substantially real-timetime-domain indication, based on the second signal, of a balance betweena sympathetic and a parasympathetic/vagal components of an autonomicnervous system. In a further embodiment, the system delivers therapy toa heart based on this indication of autonomic balance.

In another embodiment, the cardiac rhythm management system includes aheart contraction detection module, providing a heart rate intervalsignal carrying information regarding intervals between heartcontractions. A bandpass filter is coupled to the detection module forreceiving the heart rate interval signal. The bandpass filter provides atime-domain bandpass filtered signal output. A variance module iscoupled to the bandpass filter for receiving the bandpass filteredsignal. The variance modules provides a resulting variance signal. Anautonomic balance indicator module is coupled to the variance module,and provides an indication of a balance between sympathetic andparasympathetic components of an autonomic nervous system, based on thevariance signal. In a further embodiment, a therapy module, which isadapted to be coupled to a heart, provides therapy to the heart based atleast in part on the autonomic balance indication. Other aspects of theinvention will be apparent on reading the following detailed descriptionof the invention and viewing the drawings that form a part thereof.

BRIEF DESCRIPTION OF THE DRAWINGS

In the drawings, which are not necessarily drawn to scale, like numeralsdescribe substantially similar components throughout the several views.Like numerals having different letter suffixes represent differentinstances of substantially similar components. The drawings illustrategenerally, by way of example, but not by way of limitation, variousembodiments discussed in the present document.

FIG. 1 is a schematic/block diagram illustrating generally oneembodiment of portions of a cardiac rhythm management system.

FIG. 2 is a schematic/block diagram illustrating generally oneembodiment of portions of a heart rate interval extraction module.

FIG. 3 is a graph illustrating generally one embodiment of a techniquefor processing a signal that includes R-wave information includingproviding a substitute R-wave to replace a premature ventricularcontraction (PVC) or ectopic beat.

FIG. 4 is a graph illustrating generally one embodiment of a techniquefor processing a signal that includes R-wave information, includingforming a continuous-time R—R interval signal and a sampled data heartrate interval signal that includes R—R interval information.

FIG. 5 is a graph illustrating generally one embodiment of a techniquefor sampling and filtering a continuous-time R—R interval signal toobtain a resulting sampled data heart rate interval signal that includesR—R interval information.

FIG. 6 is a graph illustrating generally one embodiment of a LF/HFsignal representing autonomic balance based on an illustratedcorresponding heart (e.g., R—R) interval signal, and illustratinggenerally one embodiment of a technique for extracting one or morefeatures of the LF/HF signal to further quantify a state of thepatient's well-being.

FIG. 7 is a schematic/block diagram illustrating generally oneembodiment of portions of a cardiac rhythm management device including atherapy module providing therapy based at least in part on theindication of autonomic balance.

FIG. 8 is a schematic/block diagram illustrating generally oneembodiment of portions of a cardiac rhythm management system including ameans (such as a “sleep” detector) for identifying one or moreparticular time periods of interest for obtaining the indication ofautonomic balance.

FIG. 9 is a graph illustrating generally one technique for identifying atime period of interest for determining autonomic balance, in which thetime period of interest is based on data regarding the intervals betweenheart contractions.

DETAILED DESCRIPTION

In the following detailed description, reference is made to theaccompanying drawings which form a part hereof, and in which is shown byway of illustration specific embodiments in which the invention may bepracticed. These embodiments are described in sufficient detail toenable those skilled in the art to practice the invention, and it is tobe understood that the embodiments may be combined, or that otherembodiments may be utilized and that structural, logical and electricalchanges may be made without departing from the spirit and scope of thepresent invention. The following detailed description is, therefore, notto be taken in a limiting sense, and the scope of the present inventionis defined by the appended claims and their equivalents. In thedrawings, like numerals describe substantially similar componentsthroughout the several views. Like numerals having different lettersuffixes represent different instances of substantially similarcomponents. The term “and/or” refers to a nonexclusive “or” (i.e., “Aand/or B” includes both “A and B” as well as “A or B”).

The present methods and apparatus will be described in applicationsinvolving implantable medical devices including, but not limited to,implantable cardiac rhythm management systems such as pacemakers,cardioverter/defibrillators, pacer/defibrillators, biventricular orother multi-site coordination devices, and drug delivery systems.However, it is understood that the present methods and apparatus may beemployed in unimplanted devices, including, but not limited to, externalpacemakers, cardioverter/defibrillators, pacer/defibrillators,biventricular or other multi-site coordination devices, monitors,programmers and recorders, whether such devices are used for providing adiagnostic, a therapy, or both a diagnostic and a therapy.

This document describes a cardiac rhythm management system that providesan indication of patient well-being, based on an autonomic balancebetween the sympathetic and vagal components of the autonomic nervoussystem, using time-domain processing of frequency components of a heartrate interval signal.

FIG. 1 is a schematic/block diagram illustrating generally oneembodiment of portions of a cardiac rhythm management system 100. Inthis embodiment, system 100 includes, among other things, a cardiacrhythm management device 105 and a leadwire (“lead”) 110 forcommunicating signals between device 105 and a portion of a livingorganism, such as a heart 115. Embodiments of device 105 include, amongother things, bradycardia and antitachycardia pacemakers, cardioverters,defibrillators, combination pacemaker/defibrillators, drug deliverydevices, and any other implantable or external cardiac rhythm managementapparatus capable of providing therapy and/or diagnostics to heart 115.System 100 may also include additional components such as, for example,a remote programmer 190 capable of communicating with device 105 via atransmitter or receiver, such as telemetry transceiver 187.

In one embodiment, portions of system 100 (e.g., device 105) areimplantable in the living organism, such as in a pectoral or abdominalregion of a human patient, or elsewhere. In another embodiment, portionsof system 100 (e.g., device 105) are alternatively disposed externallyto the human patient. In the illustrated embodiment, portions of lead110 are disposed in the right ventricle, however, any other positioningof lead 110 is included within the present invention. For example, invarious alternative embodiments, lead 110 may alternatively bepositioned in a location that is associated with the right atrium and/orsuperior vena cava, the coronary sinus or great cardiac vein, the leftatrium or ventricle, epicardially, or elsewhere. In one embodiment, lead110 is a commercially available bipolar pacing lead having a tipelectrode 120 and a ring electrode 125 configured to be disposed in aright ventricle of heart 115. System 100 can also include other leadsand/or electrodes in addition to lead 110, appropriately disposed, suchas in or around heart 115, or elsewhere. For example, in one externalembodiment, device 105 is not implanted and lead 110 provides externalsurface ECG electrode connections for sensing heart signals. In aunipolar example, implanted device 105 itself includes one or moreelectrodes for sensing heart signals or providing therapy, such ashousing electrode 130 or header electrode 135.

FIG. 1 also illustrates generally portions of device 105, together withschematic illustrations of example connections to the variouselectrodes. Device 105 includes a heart contraction detection module 137that receives intrinsic heart signals from electrodes that arecommunicatively associated with heart 115. Module 137 provides an outputheart rate interval signal carrying information about the time intervalsbetween heart contractions. Because, as discussed above, the intervalbetween heart contractions manifests intrinsic variations, the outputheart rate interval signal provided by module 137 includes heart ratevariability information.

In one embodiment, module 137 includes a sense amplifier 140, which, inthis illustration, is coupled to tip electrode 120 and ring electrode125 for receiving intrinsic heart signals that include electricaldepolarizations corresponding to heart contractions (right ventricularheart contractions, in this example). Sense amplifier 140 detects suchinput heart depolarizations and provides an output electrical signalcarrying such information to subsequent portions of device 105. In afurther embodiment, sense amplifier 140 also includes filtering or othersignal processing circuits for detecting the desired electricaldepolarizations associated with heart contractions, as is known in theart. Device 105 also includes an analog-to-digital (A/D) converter 145,which receives the sensed electrical depolarization signal and providesan output digital representation thereof. In a further embodiment, A/Dconverter 145 includes associated sample and hold circuits for samplingthe electrical signal output by sense amplifier 140. Peak detector 150receives the digitized signal from A/D converter 145 and detects signalpeaks associated with heart contractions. In this embodiment, thesesignal peaks are the R-waves in the QRS complexes associated withventricular heart contractions. However, it is understood that thedisclosed structure and techniques could also be used to detect atrialheart contractions using P-waves associated with atrial depolarizations.

In the illustrated embodiment, peak detector 150 outputs informationabout the timing of each R-wave to heart interval extraction module 155.Based on this information, heart rate interval extraction module 155provides a discrete-time signal that is periodically sampled, i.e., thetime difference between such samples is uniform. Each such sampleincludes an associated time interval (“heart rate interval”)corresponding to the detected heart rate.

FIG. 2 is a schematic/block diagram, illustrating generally oneembodiment of portions of heart rate interval extraction module 155,which includes an ectopic detection/processor module 200, an R—Rinterval calculation and storage module 205, and an R—R intervalsampling and filter module 210. Heart rate interval extraction module155 outputs a sampled data heart rate interval signal 215 that includesR—R interval information. In FIG. 2, ectopic detection/processor module200 receives the detected R-wave peaks from peak detector 150. Module200 deletes, replaces, and/or suppresses from further processing ectopicR-waves (sometimes referred to as premature ventricular contractions, or“PVCs”). Ectopic R-waves do not result from a normal sinus rhythm, thatis, from a conducted atrial depolarization.

In one embodiment, ectopic detection/processor module 200 also receivesdetected P-wave peaks, corresponding to atrial depolarizations, fromelectrodes associated with an atrium and sensed by an atrial senseamplifier (not shown). This embodiment of operating ectopicdetection/processor module 200 is illustrated generally by the signalgraph of FIG. 3. The input signal 300 of FIG. 3 illustrates instances ofdetected R-wave peaks, depicted by upward arrows. In FIG. 3, anydetected R-wave for which no P-wave was detected since the precedingR-wave is deemed a PVC. PVCs are suppressed in output signal 305 fromfurther signal processing. Such PVCs are replaced in output signal 305by a substitute R-wave at the estimated time at which such R-wave wouldhave occurred had there not been an ectopic event. In FIG. 3, beatnumber 10 represents a PVC that is replaced by a substitute R-wave.

Many techniques exist for generating a substitute R-wave. In oneexample, the PVC is replaced by a substitute R-wave placed at time thatis interpolated from that of following and preceding nonectopic R-waves.Because PVCs sometimes occur in groups, however, other techniques mayalso be used. Such techniques include using a moving average-liketechnique, spline-like technique, or median-like technique. Apredetermined number of R—R intervals before and/or after the PVC may beused to calculate a time of occurrence of the substitute R-wave when aPVC occurs.

FIG. 4 is a signal graph illustrating generally one embodiment of theoperation of R—R interval calculation and storage module 205 and R—Rinterval sampling and filter module 210. R—R interval calculation andstorage module 205 receives, from ectopic detection/processor module200, a signal 220 including R-wave peaks with any substituted R-waves.Module 205 includes a timer that determines the R—R time intervalbetween detected R-wave peaks, and stores the R—R intervals in memory toprovide a resulting continuous time R—R interval signal 225. Signal 225is sampled by module 210 to produce the resulting sampled data heartrate interval signal 215, which includes R—R interval information.

In one embodiment, module 210 includes a sampling module that samplessignal 225 at a sampling frequency, f_(s), exceeding the Nyquistcriterion. For example, if the maximum expected heart rate (after PVCremoval) is 180 beats per minute, then a sampling rate that is greaterthan or equal to 6 Hz is sufficient. In one embodiment, this samplingmodule portion of module 210 also includes a finite impulse response(FIR) lowpass filter (or similar lowpass filter, averager, decimator, ordownsampler) that provides a smoothed sampled data heart rate intervalsignal 210.

In one embodiment, a three sample point FIR filter is used to sample andfilter continuous time R—R interval signal 225. These sample points areseparated from each by a time interval, ΔT_(s), where ΔT_(s) is theinverse of the sampling frequency, f_(s). In operation, if the threesample points (at times t=t_(i−1), t_(i), and t_(i+1)) fall within thesame R—R interval of continuous time R—R interval signal 225, then thatR—R interval value is used as the corresponding output sample, RR_(i).Otherwise, if the three sample points span a pair of R—R intervals(i.e., first and second R—R intervals, RR₁ and RR₂) on continuous timeR—R interval signal 225, a weighted average of the first and second R—Rinterval values is used as the corresponding output sample, RR_(i). Eachof the first and second R—R interval values is weighted according to thefraction of the time, (t_(i+1)–t_(i−1)) associated with that one of thefirst and second R—R intervals, RR₁ and RR₂. Operation of such a filteris illustrated generally by FIG. 5.

FIG. 1 also illustrates a time-domain heart rate variability (HRV)signal processing module 160 that receives the heart rate intervalsignal 215 from heart rate interval extraction module 155, and providesa resulting indicator of patient well-being. In one embodiment of HRVsignal processing module 160, the input heart rate interval signal 215is received by a low frequency (LF) bandpass filter 165 and by a highfrequency (HF) bandpass filter 170. In one embodiment, LF bandpassfilter 165 is a finite impulse response (FIR) type filter having alowpass cutoff frequency that is approximately equal to 0.15 Hz, and ahighpass cutoff frequency that is approximately equal to 0.04 Hz. As aresult, LF bandpass filter 165 outputs a filtered heart rate intervalsignal having frequency components that are primarily approximatelybetween 0.04 Hz and 0.15 Hz inclusive. In this embodiment, HF bandpassfilter 170 is an FIR type filter having a lowpass cutoff frequency thatis approximately equal to 0.40 Hz, and a highpass cutoff frequency thatis approximately equal to 0.15 Hz. As a result, HF bandpass filter 170outputs a filtered heart rate interval signal having frequencycomponents approximately between 0.15 Hz and 0.40 Hz inclusive.Appropriate infinite impulse response (IIR) filter structures could alsobe used. Since the ultimate measurement of patient well-being is basedon variance, waveform distortion is not of great concern and, therefore,the filter need not provide linear phase.

LF variance module 175 and HF variance module 180 receive the outputsignals from LF bandpass filter 165 and HF bandpass filter 170,respectively. These variance modules 175 and 180 each perform avariance-type or similar computation, respectively outputting LFvariance and HF variance signals to ratio module 185. In one embodiment,variance modules 175 and 180 each include a squaring circuit (i.e., acircuit that multiplies the input by itself to provide an output signalthat is equivalent to the input signal raised to the second power)followed by a lowpass filter (or integrator or averager) to provide theresulting output signal. This squaring and lowpass filtering operationis equivalent to a variance computation that provides an indication ofheart rate variability within the associated frequency range. In oneembodiment, the lowpass filter used by variance modules 175 and 180 isan IIR type filter having a single lowpass pole with exponentialweighting of past samples occurring during a moving time window that isapproximately between 2 and 5 minutes, inclusive, in length.

Ratio module 185 receives the LF and HF variance output signals from LFvariance module 175 and HF variance module 180, respectively, anddivides the value of the LF variance by the HF variance. The resultingLF/HF ratio output by ratio module 185 provides an indication of thesympathovagal balance between the sympathetic and parasympathetic/vagalcomponents of the autonomic nervous system. As discussed above, anincrease in the LF/HF ratio indicates an increased predominance of thesympathetic component, and a decrease in the LF/HF ratio indicates anincreased predominance of the parasympathetic component. For aparticular heart rate, the LF/HF ratio is regarded as an indication ofpatient wellness, with a lower LF/HF ratio indicating a more positivestate of cardiovascular health. In one embodiment, this LF/HF ratiooutput by ratio module 185 is itself used as a patient wellnessindicator. In further embodiments, however, this LF/HF ratio signalundergoes further processing, as discussed below.

For example, in one such further embodiment, the LF/HF ratio signaloutput by ratio module 185 is received by a lowpass filter (orintegrator or averager) 190 to provide additional smoothing of theindication of patient well-being. In one such example, lowpass filter190 is implemented as an exponential-weighted averager (i.e., morerecent samples are weighted more than older samples) over a sliding timewindow that is approximately between 2 minutes and 5 minutes inclusive,such as about 5 minutes. The resulting smoothed LF/HF ratio signaloutput by lowpass filter 190 provides a more stable indication of thepatient's sympathovagal balance; one such smoothed LF/HF ratio signal isillustrated generally, by way of example, but not by way of limitation,in the graph of FIG. 3, together with a corresponding sample heart rateinterval signal on which the smoothed LF/HF ratio is based.

In a still further embodiment, the smoothed LF/HF ratio signal isreceived by autonomic balance indicator module 195 for furtherprocessing. In one example, module 195 includes a peak detector forobtaining the local minima and/or maxima of the smoothed LF/HF ratiosignal, as illustrated in FIG. 6. Thus, in one embodiment, theindication of autonomic balance is based on one or more features of thesmoothed LF/HF ratio signal, such as the local minima (e.g., using thelowest local minima during a given time period, an average of the localminima during a given time period, etc.), the local maxima, slope of thesmoothed LF/HF ratio signal, and/or slope of portions of the LF/HFenvelope (e.g., lines drawn between successive local minima and linesdrawn between successive local maxima). In a further embodiment, thedesired indication of autonomic balance is communicate by telemetrytransceiver 187 to external programmer 190, such as for processingand/or for visual, audible, or other diagnostic display to the physicianor other user.

FIG. 7 is a schematic/block diagram illustrating generally, by way ofexample, and not by way of limitation, one embodiment of portions ofdevice 105 including a controller 700 and a therapy module 705. Therapymodule 705 provides cardiac rhythm management therapy to heart 115 viaelectrodes that are communicatively associated therewith. Examples ofsuch therapy include, without limitation, atrial or ventricular pacingtherapy, antitachyarrhythmia therapy, multi-site coordination therapysuch as biventricular pacing, drug delivery. In one such embodiment, theparameters of such therapy are adjusted and/or optimized by controller700 based at least in part on one or more indications ofsympathetic/parasympathetic balance obtained from time-domain HRV signalprocessing module 160. For example, such parameters for providing dualchamber pacing therapy are well known in the art (e.g., rate, amplitude,pulsewidth, AV-delay, etc.); such parameters are adjusted, eitherindividually or in combination, to increase or decrease a particularindication of autonomic balance (e.g., to decrease the lowest localminima of the smoothed LF/HF signal). Such parameter optimization isperformed either in device 105 or, alternatively, in external programmer190.

In another example, the real-time (i.e., not substantially delayed)indicator of sympathetic/vagal balance provided by module 160 alerts thedevice to time periods during which heart 115 is particularlysusceptible to tachyarrhythmias, such as when the smoothed or unsmoothedLF/HF signal increases (e.g., beyond a threshold value or at a rate thatexceeds a threshold rate). In this embodiment, the increase in the LF/HFindication predicts the likely present or future onset of atachyarrhythmia and, as a result, controller 700 triggers the deliveryof preventative antitachyarrhythmia therapy to prevent the occurrence ofthe tachyarrhythmias. Such antitachyarrhythmia therapy includesantitachyarrhythmia pacing (ATP) sequences and/or antiarrhythmic drugtherapy using drugs that increase parasympathetic and/or decreasesympathetic activity. Thus, this embodiment provides real-time controlof therapy delivery based on the then-existing (or slightly delayed)indication of sympathetic/vagal balance.

FIG. 8 is a schematic/block diagram illustrating generally, by way ofexample, but not by way of limitation one embodiment of portions ofdevice 105 in which controller 700 (or, alternatively, externalprogrammer 190) includes a “sleep detector” module 800 or other similarmodule for identifying, one or more particular time periods of interestfor obtaining the indication of synpathetic/vagal balance. In oneembodiment, sleep detector 800 includes a long term (e.g., 24 hour)averager 805 for storing the long term average interval between heartcontractions (e.g., R—R interval), and a long term (e.g., 24 hour) peakdetector 810 for storing a corresponding long term maximum intervalbetween heart contractions (e.g., maximum R—R interval). In thisembodiment, autonomic balance indicator module 195 of FIG. 1 provides anindication of patient well-being based on sympathetic/vagal balance asobtained only when the interval between heart contractions exceeds thelong term average value over a time period that: (1) extends forward intime from the time corresponding to the maximum interval between heartcontractions to the first time, T_(f), at which the interval betweenheart contractions drops back to the long term average value: and (2)extends backward in time from the time corresponding to the maximuminterval between heart contractions to a time that is not more than 8hours (by way of example) earlier than the time T_(f). Intervals duringthis time period in which the interval between heart contractions isless than the long term average value are, in one embodiment, ignoredfor the purposes of providing an indication ofsympathetic/parasympathetic balance. This described technique isillustrated generally, by way of example, but not by way of limitation,in FIG. 9. This technique is particularly useful for ascertaining longerterm (e.g., over a period of days or months) variations in the patient'swell-being as determined from sympathetic/parasympathetic balance.Because exercise, posture, and even being awake affect thesympathetic/parasympathetic balance, these factors are de-emphasized forascertaining such longer term variations in the patient's well-being.While the time periods used in such techniques may be deemed “sleep,” asreferred to in this document by the use of the term “sleep detectormodule,” it is understood that such times may not correspond exactly toperiods during which the patient is sleeping. Other suitable timeperiods may also be used to de-emphasize components of the patient'ssympathetic/vagal balance that tend to confound an assessment oflong-term well-being.

CONCLUSION

This document describes, among other things, a cardiac rhythm managementsystem that provides an indication of patient well-being based on theautonomic balance between the sympathetic and vagal components of theautonomic nervous system, using time-domain processing of frequencycomponents of a heart rate interval signal. It is to be understood thatthe above description is intended to be illustrative, and notrestrictive. For example, the above-described embodiments may be used incombination with each other. Many other embodiments will be apparent tothose of skill in the art upon reviewing the above description. Thescope of the invention should, therefore, be determined with referenceto the appended claims, along with the full scope of equivalents towhich such claims are entitled. In the appended claims, the terms“including” and “in which” are used as plain-English equivalents of therespective terms “comprising” and “wherein.”

1. A method including: detecting ventricular heart contractions over atime period; detecting atrial heart contractions over the time period;if any ventricular heart contraction is not preceded by a correspondingatrial contraction, then deeming that ventricular heart contraction apremature ventricular contraction (PVC); replacing the PVC with asubstitute R-wave at that time which the R-wave would have occurred hadthe PVC not occurred; obtaining a time-domain first signal representingtime intervals between the detected ventricular heart contractions,wherein the detected ventricular heart contractions include anysubstitute R-waves generated as a result of a PVC; filtering the firstsignal to obtain a time-domain second signal including frequencycomponents substantially in a first frequency band, wherein the secondsignal is influenced by both sympathetic and parasympathetic componentsof an autonomic nervous system; filtering the first signal to obtain atime-domain third signal including frequency components substantially ina second frequency band, wherein the third signal is influenced by theparasympathetic component of the autonomic nervous system and notsubstantially influenced by the sympathetic component of the autonomicnervous system; obtaining a time domain variance of each of the secondand third signals; and providing an indication associated with a balancebetween the sympathetic and parasympathetic components of the autonomicnervous system based on a ratio between the time-domain variances of thesecond and third signals.
 2. The method of claim 1, in which thereplacing the PVC with a substitute R-wave includes interpolating a timeof the substitute R-wave from a most recent nonectopic ventricularcontraction and an earliest subsequent nonectopic ventricularcontraction.
 3. The method of claim 1, in which the replacing the PVCwith a substitute R-wave includes computing a time of the substituteR-wave using a moving average.
 4. The method of claim 1, in which thereplacing the PVC with a substitute R-wave includes using a spline tocompute a time of the substitute R-wave.
 5. The method of claim 1, inwhich the replacing the PVC with a substitute R-wave includes using amedian to compute a time of the substitute R-wave.
 6. The method ofclaim 1, in which the replacing the PVC with a substitute R-waveincludes using a number of RR intervals before the PVC to compute a timeof the substitute R-wave.
 7. The method of claim 1, in which thereplacing the PVC with a substitute R-wave includes using a number of RRintervals after the PVC to compute a time of the substitute R-wave. 8.The method of claim 1, wherein obtaining the variance comprises:squaring each of the second and third signals; and lowpass filteringeach squared second and third signals.
 9. The method of claim 1, furtherincluding lowpass filtering the ratioed variance of the second and thirdsignals.
 10. The method of claim 1, in which providing an indicationassociated with an autonomic nervous system includes extracting a signalfeature of the ratioed variance of the second and third signals.
 11. Amethod including: detecting heart contractions over a time period;obtaining a time-domain first signal representing time intervals betweenthe detected heart contractions; filtering the first signal to obtain atime-domain second signal including frequency components substantiallyin a first frequency band, wherein the second signal is influenced byboth sympathetic and parasympathetic components of an autonomic nervoussystem; filtering the first signal to obtain a time-domain third signalincluding frequency components substantially in a second frequency band,wherein the third signal is influenced by the parasympathetic componentof the autonomic nervous system and not substantially influenced by thesympathetic component of the autonomic nervous system; obtaining a timedomain variance of each of the second and third signals; providing abalance indication associated with a balance between the sympathetic andparasympathetic components of the autonomic nervous system based on aratio between the time-domain variances of the second and third signals;and automatically adjusting a therapy at least in part by using thebalance indication to control the adjusting.
 12. The method of claim 11,in which the adjusting the therapy includes using a present value of thebalance indication.
 13. The method of claim 11, in which the adjustingthe therapy includes using a delayed value of the balance indication.14. The method of claim 11, in which the adjusting the therapy includesselecting at least one therapy parameter value so as to increase a valueof the balance indication.
 15. The method of claim 11, in which theadjusting the therapy includes selecting at least one therapy parametervalue so as to decrease a value of the balance indication.
 16. Themethod of claim 11, in which the balance indication is an LF/HF signal,and in which adjusting the therapy includes delivering a preventativeantitachyarrhythmia therapy when a value of the balance indicationexceeds a threshold value.
 17. The method of claim 11, in which theadjusting the therapy includes using the balance indication to controlthe adjusting in real-time.
 18. A method including: detecting heartcontractions over a time period; obtaining a time-domain first signalrepresenting time intervals between the detected heart contractions;filtering the first signal to obtain a time-domain second signalincluding frequency components substantially in a first frequency band,wherein the second signal is influenced by both sympathetic andparasympathetic components of an autonomic nervous system; filtering thefirst signal to obtain a time-domain third signal including frequencycomponents substantially in a second frequency band, wherein the thirdsignal is influenced by the parasympathetic component of the autonomicnervous system and not substantially influenced by the sympatheticcomponent of the autonomic nervous system; obtaining a time domainvariance of each of the second and third signals; and providing anindication associated with a balance between the sympathetic andparasympathetic components of the autonomic nervous system based on aratio between the time-domain variances of the second and third signalsduring a period of time that is deemed to correspond to a resting state.19. The method of claim 18, in which during the period of time aninterval between adjacent heart contractions generally exceeds along-term average value.
 20. The method of claim 19, in which the periodof time includes a first interval that extends forward from a first timecorresponding to a maximum interval between adjacent heart contractionsto a second time when the interval between adjacent heart contractionsfirst drops back to the long-term average value.
 21. The method of claim20, in which the period of time includes a second interval that extendsbackward in time from a third time corresponding to a maximum intervalbetween adjacent heart contractions to a fourth time that is not morethan a fixed time amount earlier than the third time.
 22. The method ofclaim 19, in which the period of time includes a second interval thatextends backward in time from a first time corresponding to a maximuminterval between adjacent heart contractions to a second time that isnot more than a fixed time amount earlier than the first time.